First came the bad news on Nov. 19: Orlando Health plans to cut 2 to 3 percent of its labor costs, which could impact 320 to 480 positions through immediate layoffs, attrition and retirements, effective immediately.

And now for the sour cherry on top: Orlando Health will spend six to eight months examining service lines at its eight campuses to see what programs may be eliminated.

“God bless all our health care providers,” said Ken Peach, executive director of the Health Council of East Central Florida. “We’re facing a very difficult time in health care. It’s the movement from fee-for-service — do more and charge more for it — to a value-based system. It’s going to be very uncomfortable for every health care provider to suddenly shift how you’re reimbursed.”

So what does that mean for operations at Central Florida’s fifth-largest employer with 16,000 employees?

Insiders and analysts agreed there are three basic criteria that could put a service line on the chopping block: Does it lose money, is it mission critical, and is it readily available at other hospitals.

Here’s a look at areas that analysts said might make sense to put on the chopping block:

• Level 1 trauma designation: There are two types of trauma cases: blunt trauma — usually car accidents — and penetration trauma, the so-called “gun-and-knife club.” Blunt trauma patients tend to have health insurance or, at a minimum, some coverage from auto insurance to cover medical bills from an uninsured driver. Gunshot and knife wound victims, well, not so much.

Orlando Regional Medical Center is Central Florida’s only Level 1 trauma center. That means it gets more than its fair share of gunshot and knife wound victims. Analysts said if the hospital backed off from its Level 1 trauma center designation, more of those patients would be disbursed to other area emergency departments. Still, it’s hard to imagine Orlando Health without its Level 1 trauma center.

• Obstetrics and newborn care: Orlando Health would never close its Arnold Palmer or Winnie Palmer hospitals. But the fact is, birthing babies and caring for them afterward are two service lines that can be loss leaders for a hospital, although they’re arguably mission critical. Analysts said it’s possible Orlando Health could consolidate, closing down obstetrics units at outlying hospitals and bringing all those services downtown.

• Behavioral health: This falls in the same category as obstetrics and newborn care — easily considered mission critical, but still a lot of red ink. Analysts said Orlando Health could consolidate its psychiatric and substance abuse programs to South Seminole Hospital in Longwood.

• Graduate medical education: This is another touchy one. It costs millions of dollars every year to have faculty and staff train the next generation’s young doctors. That means the program could have a target on its back. But, it’s also hard to imagine Orlando Health giving up its status as the area’s dominant teaching hospital.

• Outpatient services: Hospitals are designed for inpatient, acute and critical patients. It’s where the sickest of the sick go so they don’t die. That means anything in the outpatient world losing money likely will be on the chopping block.

• Community events and outreach: Orlando Health is a nonprofit institution dedicated to the health of the community. That being said, spending money on health fairs and outreach that won’t have immediate impacts may be cut.

“Sometimes it doesn’t make sense to split [a service line] up among multiple hospitals, because no one gets enough surgeries and economies of scale,” said John Bigalke, senior partner of global health care for Charlotte, N.C.-based Deloitte LLP. “We don’t get enough volume to open up the doors, so we need to get rid of it and shift to another provider.”

Orlando Health officials declined to comment on the potentials outlined above, saying the list is “pure speculation at this point.”

Orlando Health already was feeling the pain, posting a $2.9 million loss in third-quarter 2012, in part because Medicaid payments this year had been cut by $59 million, with another $8 million in cuts expected next year. It plans to release its fourth-quarter results Nov. 23.

“For Orlando Health, and specifically its main campus, ORMC, it’s slim pickings because of the mission,” said Michael Carroll, an analyst with Tampa-based Tribrook Healthcare Consultants.

Even so, Deloitte’s Bigalke said the cost-cutting, while painful, ultimately is good for the health care system.

“It’s a good sign [Orlando Health] is stepping back and saying ‘the status quo isn’t going to work, we’ve got to be more efficient,’ ” Bigalke said. “When you start moving into a more efficient environment, there are going to be winners and losers.”

What this means to you:

• Elimination of 320 to 480 positions, with potentially more to come in 2013, will affect the local economy.

• Orlando Health may cut service lines that lose money and are readily available elsewhere, which could make it more difficult for your employees to get treatment for certain ailments.

What’s not at stake

• Future capital expenditures are on hold, but not announced ones. That means the $297 million new patient tower and renovations at Orlando Regional Medical Center and the $25 million new proton therapy facility project are safe

• The $50 million purchase of Physician Associates LLC is still a go, with plans to close on the deal Dec. 31

• Nursing jobs are safe, although nursing manager positions will be eliminated; those employees can apply for open nursing jobs, though.